SHOPKO STORES OPERATING CO. LLC (NPI# 1700839545) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1700839545 |
| Entity Type | Organization |
| Organization Name | SHOPKO STORES OPERATING CO. LLC |
| Other Organization Name | SHOPKO OPTICAL 104 |
| Practice Address |
747 S Main St Brigham City UT 84302-3359 |
| Practice Telephone | 4357231800 |
| Mailing Telephone | 4357231800 |
| Enumeration Date | 2006-05-19 |
| Last Update Date | 2008-07-10 |
| Authorized Official Name | MICHAEL J BETTIGA (SR. VICE PRESIDENT HEALTH SERVICES) |
| Authorized Official Telephone | 9204294297 |
| Authorized Official Credential | RPH |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 152W00000X | Optometrist | Eye and Vision Services Providers | ||
| N | 156FX1800X |
Technician/Technologist Specialization: Optician |
Eye and Vision Services Providers | ||
| Y | 332H00000X | Eyewear Supplier (Equipment, not the service) | Suppliers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| VIP | 014104 | 01 | |
| UT | NORIDIAN SUBMITTER ID | UT04883 | 01 |
| EYEMED | CP2230-41 | 01 | |
| MEDICARE | 17927 | 01 | |
| AVESIS | 35524 | 01 | |
| UT | 410985054-165 | 05 |
| Other Name | Type Code |
|---|---|
| ShopKo Optical 104 | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1952356644 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 700 Pilgrim Way, Green Bay, WI 54304-5263 | 2006-05-23 |
| 1124071568 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 500 N Hwy 281, Aberdeen, SD 57401-1821 | 2006-05-18 |
| 1760435333 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 3030 Wabash Ave, Springfield, IL 62704-6413 | 2006-05-18 |
| 1679526263 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 1640 Appleton Rd, Menasha, WI 54952-1106 | 2006-05-18 |
| 1003869678 | Shopko Stores Operating Co. LLC | Technician/Technologist | 2120 Thain Grade, Lewiston, ID 83501-4105 | 2006-05-18 |
| 1457304024 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 1001 Highway 15 S, Fairmont, MN 56031-4456 | 2006-05-18 |
| 1497708085 | Shopko Stores Operating Co. LLC | Technician/Technologist | 217 W Ironwood Dr, Coeur D Alene, ID 83814-2651 | 2006-05-18 |
| 1902859515 | Shopko Stores Operating Co. LLC | Technician/Technologist | 301 Northwest Byp, Great Falls, MT 59404-4125 | 2006-05-18 |
| 1750334348 | Shopko Stores Operating Co. LLC | Technician/Technologist | 3101 N Montana Ave, Helena, MT 59602-7813 | 2006-05-18 |
| 1083667638 | Shopko Stores Operating Co. LLC | Eyewear Supplier (Equipment, not the service) | 5300 52nd St, Kenosha, WI 53144-2310 | 2006-05-17 |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| Oregon Corporations, Companies and Business Names | SHOPKO STORES OPERATING CO., LLC | 700 Pilgrim Way, Green Bay, WI 54304 |
| Colorado Business Entities | ShopKo Stores Operating Co., LLC | 700 Pilgrim Way, Green Bay, WI 54304 |
| Iowa Business Entities | SHOPKO STORES OPERATING CO., LLC | 700 Pilgrim Way, Green Bay, WI 54304 |
| Washington State Corporations | SHOPKO STORES OPERATING CO., LLC | 700 Pilgrim Way, Green Bay, WI 54304-5263 |
| Street Address |
747 S MAIN ST |
| City | BRIGHAM CITY |
| State | UT |
| Zip Code | 84302-3359 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1386694677 | Scott Roberts Haderlie | Optometrist | 747 S Main St, Brigham City, UT 84302-3359 | 2006-05-10 |
| 1649221623 | Shopko Stores Operating Co LLC | Durable Medical Equipment & Medical Supplies | 747 S Main St, Brigham City, UT 84302-3359 | 2006-05-13 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1669945531 | Brandon Lee Allen | Counselor | 971 South 800 West, #104, Brigham City, UT 84302 | 2019-01-03 |
| 1104307495 | Tiffany Burnhope | Social Worker | 663 Parker Lane, Brigham City, UT 84302 | 2018-08-24 |
| 1558858464 | Michael Clark | Optometrist | 990 Medical Dr Ste G3, Brigham City, UT 84302 | 2018-04-16 |
| 1497273130 | Emily Marler | Counselor | 862 South Main Suite 4, Brigham City, UT 84302 | 2017-09-01 |
| 1003268731 | Tyler Beckstrand | Social Worker | 125 N Main Street, Brigham City, UT 84302 | 2016-07-06 |
| 1780030155 | Angela Stott | Case Manager/Care Coordinator | 160 E 800 S Apt. B216, Brigham City, UT 84302 | 2016-05-04 |
| 1699156802 | Christopher Jacobson | Family Medicine | 1050 Medical Dr, Brigham City, UT 84302 | 2015-06-12 |
| 1811377765 | Courtney Allred | Counselor | 863 S Main Street Suite 2, Brigham, UT 84302 | 2015-06-05 |
| 1235529579 | Belinda Castro | Counselor | 862 S Main Street Suite 2, Brigham City, UT 84302 | 2015-01-26 |
| 1760871818 | Ambryn Mccallson | Counselor | 862 S. Main, 4, Brigham City, UT 84302 | 2015-01-13 |
| Find all providers in zip 84302 | ||||
| Taxonomy Code | 332H00000X |
| Grouping | Suppliers |
| Classification | Eyewear Supplier (Equipment, not the service) |
| An organization that provides spectacles, contact lenses, and other vision enhancement devices prescribed by an optometrist or ophthalmologist. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1811217383 | Larry D Terry A Professional Corporation | Eyewear Supplier (Equipment, not the service) | 34 S Main St, Brigham City, UT 84302-2527 | 2010-06-08 |
| 1497932826 | Alan Optical, Inc. | Eyewear Supplier (Equipment, not the service) | 990 Medical Dr, G2, Brigham City, UT 84302-4713 | 2008-01-29 |
| 1104924836 | Vision Experts Inc | Eyewear Supplier (Equipment, not the service) | 990 Medical Dr, Brigham City, UT 84302-4713 | 2006-09-20 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1053935882 | Eyemart Express LLC | Eyewear Supplier (Equipment, not the service) | 15 S River Rd # 150, St George, UT 84790-2106 | 2020-06-08 |
| 1265088074 | Eyemart Express LLC | Eyewear Supplier (Equipment, not the service) | 846 Expressway Ln, Spanish Fork, UT 84660-1300 | 2019-08-16 |
| 1407412885 | Shoptikal LLC | Eyewear Supplier (Equipment, not the service) | 1520 W 9000 S Ste E, West Jordan, UT 84088-8001 | 2019-05-11 |
| 1043876428 | Shoptikal LLC | Eyewear Supplier (Equipment, not the service) | 2843 S 5600 W Ste 170, West Valley City, UT 84120-6089 | 2019-05-11 |
| 1134785512 | Shoptikal LLC | Eyewear Supplier (Equipment, not the service) | 2035 Harris Blvd Ste C, Layton, UT 84041-1655 | 2019-05-11 |
| 1124584529 | Eyemart Express LLC | Eyewear Supplier (Equipment, not the service) | 1986 N Hill Field Rd Ste 5, Layton, UT 84041-2112 | 2019-02-11 |
| 1003383803 | Jand. Inc. | Eyewear Supplier (Equipment, not the service) | 918 E 900 S, Salt Lake City, UT 84105-1402 | 2018-10-30 |
| 1356826010 | Eyemart Express LLC | Eyewear Supplier (Equipment, not the service) | 4115 Riverdale Rd, Ogden, UT 84405-3509 | 2018-09-28 |
| 1003398025 | Eyemart Express LLC | Eyewear Supplier (Equipment, not the service) | 366 E University Pkwy, Orem, UT 84058 | 2018-09-06 |
| 1790225696 | Luxottica of America Inc | Eyewear Supplier (Equipment, not the service) | 6117 S State St, Murray, UT 84107-7343 | 2017-02-27 |
| Find all providers with the same taxonomy | ||||
| City | BRIGHAM CITY |
| Zip Code | 84302 |
Please comment or provide details below to improve the information on SHOPKO STORES OPERATING CO. LLC.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.